Body Composition and Anthropometric Form

Transcription

1 Body Composition and Anthropometric Form FORM CODE: BCF VERSION B 10/16/2008 ID NUMBER: CONTACT: 0 9 LAST NAME: INITIALS: INSTRUCTIONS: This form is to be completed during the participant s clinic visit ID Number, Contact Year, and Name must be entered above Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost box Enter leading zeroes where necessary to fill all boxes If using a paper form and a number is entered incorrectly mark through the incorrect entry with an X Code the correct entry clearly above the incorrect entry For multiple choice and yes/no type questions, circle the correct code corresponding to the most appropriate response If a number is circled incorrectly, mark through it with an X and circle the correct response A PRELIMINARY INFORMATION 1 When was the last time you had anything to drink including water? TIME : h h m m 2 If you drink alcohol, have you had any alcoholic beverages in the last 48 hours? Don t drink alcohol 1 Yes 2 No 3 3 Have you engaged in any moderate or vigorous physical activity within the past 12 hours? Yes 1 No 2 4 [ASK WOMEN ONLY 55 YEARS OR YOUNGER: ENTER CODE 4 IF FEMALE 56 YEARS OR >; ENTER CODE 5 IF MALE] Have you had a menstrual period within the past two weeks? No longer menstruating 1 Yes 2 No 3 Female 56/older 4 Male 5 BCF Version B 10/16/2008 Page 1 of 5

2 B GIRTH MEASUREMENTS 5 Waist girth (to the nearest inch) 6 Hip girth (to the nearest inch) RECORD MEASUREMENTS USING BOTH THE BALANCE BEAM SCALE/WALL MEASURE OF STANDING HEIGHT AND THE TANITA BODY COMPOSITION SCALE AND HEIGHT ROD FOR BALANCE BEAM MEASURES, BMI IS CALCULATED AUTOMATICALLY ENTER THE BMI MEASUREMENT FROM THE TANITA OUTPUT Complete Section C ONLY 7 Was this participant s height, weight, and BMI measured by: Balance beam/wall only 1 Complete Section D ONLY Complete Section C AND D Tanita body composition only 2 Both 3 Don t Know 7 Refused 8 Missing 9 C BALANCE BEAM/WALL MEASUREMENT 8 Standing height (to nearest inch): 8a 8b feet inches 9 Weight (to nearest tenth of pound): 10 Body mass index (to nearest tenth of a unit) 9 8 Kg/m 2 BCF Version B 10/16/2008 Page 2 of 5

3 D TANITA MEASUREMENTS 11 Body Type Standard 1 Athletic 2 12 Height (TANITA) 12a Feet 12b Inches 13 Weight (TANITA) (to the nearest tenth of pound 14 Body Mass Index (TANITA) Percent Body Fat (to the nearest tenth of a percent) 16 Basal Metabolic Rate 16a b 17 Impedance Ω 18 Fat Mass (to the nearest tenth of a percent) % 19 Fat Free Mass d BCF Version B 10/16/2008 Page 3 of 5

4 20 Total Body Water E DESIRABLE RANGE 21 Desirable Percent Body Fat - % 22 Desirable Fat Mass F GOAL SETTING 23 Target Percent Body Fat % 24 Predicted Fat Mass Fat to Lose G ADMINISTRATIVE INFORMATION 26 Date of data collection: / / m m d d y y y y 27 Method of data collection: Computer 1 Paper form 2 28 Data collected: In Clinic 1 Off site 2 BCF Version B 10/16/2008 Page 4 of 5

5 29 Code number of person completing this form: BCF Version B 10/16/2008 Page 5 of 5